Report Date


Case Against



Independent Health Care providers

Case Reference Number



Voluntary settlement

Mrs A complained about the robustness and accuracy of a Stage 2 investigation undertaken by the Council into the care and support provided to her late mother (Mrs C) by an Extra Care Facility operated by Pobl. The Ombudsman commenced an investigation into the appropriateness of the Stage 2 investigation against the Council and exercised discretion and commenced an investigation against Pobl in relation to the substantive aspects of Mrs A’s complaint.

The Council undertook an internal review of the Stage 2 investigation and identified that certain aspects of the investigation report were not as robust as it would expect. It was not satisfied that there was sufficient evidence to support all of the findings.

The Council agreed to undertake the following actions:

• Within 1month apologise to Mrs A for the issues identified within the internal review in relation to the robustness of the original Stage 2 investigation and provide her with a redress payment of £450 in recognition of the inconvenience and distress of pursuing the complaint

• Within 4months undertake a further Stage 2 investigation (undertaken by a new Independent Investigator). Whilst the remit of the investigation is to be agreed between Mrs A and the Independent Investigator, the investigation will consider as a minimum:

• Whether care staff should have undertaken checks on Mrs C overnight between 23 and 24 January 2020 and whether these checks were carried out

• Whether care staff applied Timodine cream as directed between 13 January and 23 January 2020

• Whether the care staff ensured Mrs C’s skin integrity was monitored in January 2020 given the moisture damage that she had around her groin and sacrum area upon attendance at hospital

• Whether care staff should have arranged for Mrs C to be moved off the commode sooner on 23 January 2020